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Arrhythmias/Pacemakers trouble shooting
• Magdi Sami, MD, FRCP(C), FACC
• Professor of Medicine, MCGILL Univ.
• Senior Cardiologist, MUHC
Learning objectives
• Complex ECG’s arrhythmia analysis
• Basic troubleshooting of pacemaker malfunctions.
What is the heart rate?What is the rhythm?What is the heart rate?What is the rhythm?
33 x 6 = 198 bpm
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
What is the rate? The rhythm?What is the rate? The rhythm?
Short R deep S in V5, V6 pathognomonic of VT
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
This is a recording from an 80 year old man. He was taking Hytrin, Metoprolol, Adalat, Dyazide and ASA.
Pacemaker trouble shootPacemaker trouble shootOutlineOutline
1.1. Pacemaker codesPacemaker codes
2.2. Pacemaker configurationPacemaker configuration
3.3. ExamplesExamples
Pacemaker CodesPacemaker Codes
PositionPosition
FunctionFunction
11
Chambers Chambers PacedPaced
22
Chambers Chambers SensedSensed
33
Response to Response to Sensed Sensed StimulusStimulus
44
Rate Rate Modulation?Modulation?
O (none)O (none) OO OO O (non-rate O (non-rate responsive)responsive)
A (atrium)A (atrium) AA T (triggered)T (triggered) R (rate R (rate responsive)responsive)
V (ventricle)V (ventricle) VV I (inhibited)I (inhibited)
D (both atrium & D (both atrium & ventricle)ventricle)
Pacemaker ConfigurationsPacemaker ConfigurationsVOOVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsPacemaker ConfigurationsAAIAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation.
Pacemaker ConfigurationsPacemaker ConfigurationsDDDDDD
Indications1. The combination of AV block and SSS.2. Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO.
Problem with Pacemaker?Problem with Pacemaker?
Causes: • Threshold rise (electrolytes, drugs)• Lead dislodgement• Lead fracture• RV infarct
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Problem with Pacemaker?Problem with Pacemaker?
Causes: • Oversensing• Battery failure• Internal insulation failure• Conductor coil fracture
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Problem with Pacemaker?Problem with Pacemaker?
Causes: • Crosstalk
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Problems with PacemakersProblems with Pacemakers
Causes: • Undersensing• Lead Fracture
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Is this pacemaker capturing?Is this pacemaker capturing?
Atrial sensed, ventricular paced
Consistent with DDD or VDD
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
What’s wrong?What’s wrong?
Failure to Pace
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
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